Introduction

Medial epicondylitis occurs less frequently than its lateral counterpart and is commonly referred to as golfer's elbow, although many patients with this condition are not golfers. Medial epicondylitis is a pathological condition involving the origin of the common flexors; hence, any activity, whether recreational or occupational, involving repetitive stressing of the wrist flexors, makes an individual susceptible to medial epicondylitis. In addition to golf, tennis is another sport implicated in the development of medial epicondylitis, specifically in players who hit a great deal of topspin during the forehand stroke. Because of this, medial epicondylitis has also been called "professional tennis elbow." Persons with occupations involving tedious repetitive activities that require manual dexterity such as electronics repair, plumbing, and tailoring, are often particularly prone to developing medial epicondylitis; however, lateral epicondylitis remains a more common occupational hazard.

Although the term epicondylitis suggests an inflammatory etiology, from a histological perspective, few inflammatory cells are present in this condition. Instead, repetitive microtrauma at the common flexor origin leads to intratendinous tearing that heals through a process termed by Nirschl as angiofibroblastic hyperplasia.¹ Medial epicondylitis typically involves the origins of the pronator teres and flexor carpi radialis but may also involve the palmaris longus, flexor carpi ulnaris, and flexor sublimus.² Additionally, long-standing severe cases may evolve into partial or complete rupture of the common flexor origin.

Nirschl has categorized epicondylitis based on pathological findings, clinical signs, and treatment implications.³ Category I is characterized by acute inflammation (no angiofibroblastic invasion), activity-related pain, and good response to activity modification and anti-inflammatory measures. Category II is characterized by partial angiofibroblastic invasion, rest pain, and reasonable response to nonoperative treatment, although some patients may ultimately require surgery. Category III is characterized by extensive angiofibroblastic invasion with partial or complete tendon disruption, night pain, and pain preventing routine activities of daily living, and ultimately requires surgical treatment.

Clinical Features

Patients with medial epicondylitis most commonly complain of medial sided elbow pain exacerbated by activities requiring active wrist flexion. If symptoms have been present for an extended period of time, patients may also complain of rest pain or night pain. Almost all patients with medial epicondylitis have a history of performing some type of repetitive recreational or occupational activity requiring active wrist flexion.

A thorough elbow examination should be performed on patients with suspected medial epicondylitis. Typically, patients report exquisite tenderness with palpation in the region of the medial epicondyle. Additionally, pain occurs at the medial epicondyle with resisted wrist flexion.

Ulnar nerve neuritis occurs in up to 40% of patients with medial epicondylitis.² Assessing the ulnar nerve in patients with suspected medial epicondylitis is important and can be done effectively with physical examination (eg, Tinel's sign, tenderness). In cases in which ulnar nerve involvement is unclear, electromyographic studies may be beneficial. Medial collateral ligament injuries can also mimic medial epicondylitis and may occur concomitantly in up to 2% of patients with medial epicondylitis.²

Radiographic Findings

Plain radiographic images usually appear normal in patients with medial epicondylitis. Secondary imaging is rarely indicated in cases of medial epicondylitis. If concomitant medial collateral ligament injury is suspected, further imaging with stress radiography or magnetic resonance imaging is useful.

Treatment

Initial management of medial epicondylitis is nonoperative treatment consisting of activity modification, physical therapy, and nonsteroidal anti-inflammatory medications. Patients are requested to temporarily avoid inciting activities until symptoms subside. Physical therapy consists of mobility exercises that do not reproduce symptoms and modality treatment including cryotherapy, electrical stimulation, ultrasound, or ionophoresis. Nonsteroidal anti-inflammatory medications are generally used over a 6-week period. Patients failing this initial regimen of nonoperative treatment are candidates for corticosteroid injection. During corticosteroid injection, care is taken to avoid intraneural injection of the ulnar nerve. After the injection is performed, patients continue the previously described nonoperative interventions. Additional injections, spaced approximately 6 weeks apart, can be considered for patients who initially had a good response to corticosteroid injection but ultimately had a return of symptoms. No universal agreement exists on how many injections can be performed. As symptoms subside, patients are allowed to gradually resume their activities.

Operative intervention is considered for patients failing a 6- to 12-month course of nonoperative treatment. Surgical treatment consists of surgical excision of the pathological tissue. For medial epicondylitis, excision is performed openly; percutaneous and arthroscopic techniques are contraindicated as they potentially endanger the ulnar nerve. Additionally, care must be taken to debride only the pathological tissue and avoid damage to the medial collateral ligament. If ulnar neuritis coexists, the ulnar nerve is released and transposed at the time of medial epicondyle debridement. The success rate of surgical treatment is approximately 90%.⁴ After surgery, a short period of immobilization is followed by progressive rehabilitation, usually allowing resumption of preinjury activities between 3 and 6 months postoperatively.

References

1. Nirschl RP, Pettrone FA. Tennis elbow: The surgical treatment of lateral epicondylitis. J Bone Joint Surg Am. 1979; 61:832-839.
   
    
2. Nirschl RP. Lateral and medial epicondylitis. In: Morrey BF, ed. The Elbow. New York, NY: Raven Press; 1994:129-148.
   
    
3. Nirschl RP. Muscle and tendon trauma: Tennis elbow. In: Morrey BF, ed. The Elbow and Its Disorders. 2nd ed. Philadelphia, Pa: WB Saunders; 1993:537-552.
   
    
4. Vangness CT Jr, Jobe F. The surgical treatment of medial epicondylitis. Results in 35 elbows. J Bone Joint Surg Br. 1991; 73:409-411.